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February 2011 January 2013 Retinal pharmacotherapy for the anterior segment surgeon EW FEATURE 39 Treatment preferences for age-related macular degeneration vary among retina specialists by Ellen Stodola EyeWorld Staff Writer Physicians see some promising strategies and advancements for future treatment of AMD. T reatment options for age-related macular degeneration (AMD) have been evolving, showing improvement in previous therapy and drug options. Because AMD causes loss of central vision, leaving patients the ability to only see through peripheral vision, experts say it is vital to detect early signs of AMD so that a person with the condition can be treated or referred to a specialist quickly. AMD therapy and drug choices Peter Kaiser, M.D., Cole Eye Institute, Cleveland Clinic, Cleveland, said he chooses between a combination treatment or monotherapy to treat AMD patients. "It obviously depends on the patient," he said. For example, he said someone who has polypoidal choroidal vasculopathy, a condition he said is seen more often in darkly pigmented individuals or those in the Asian demographic, may need to be treated right away with a combination of photodynamic therapy (PDT) and anti-VEGF injections. But he mainly uses monotherapy for choroidal neovascularization (CNV) patients. Dr. Kaiser said he uses several different drug treatments, including Avastin (bevacizumab, Genentech, San Francisco), Lucentis (ranibizumab, Genentech) and EYLEA (Regeneron Pharmaceuticals, Tarrytown, N.Y.). "In general, I treat my patient with either Lucentis or EYLEA if they have insurance coverage. If they don't have insurance coverage or are paying out of pocket, I'll use Avastin," Dr. Kaiser said. He said his decision of which product to use is based both on cost and safety. "We've had several major studies looking at the differences between the drugs, and from an efficacy standpoint, visual acuity standpoint, the drugs are very similar," Dr. Kaiser said. He said you have to dig deeper to pinpoint differences. Although currently there is a question of a difference in safety among the drugs, this has not been proven either way yet. "Lucentis and EYLEA appear to dry the retina better, and what that means long term still remains to be seen," Dr. Kaiser said. He also said he likes to use drugs that are not fractionated or compounded if he can avoid it. Justin L. Gottlieb, M.D., associate professor, Department of Ophthalmology, University of Wisconsin, Madison, said when it comes to treating AMD, he generally uses monotherapy and rarely uses any combination therapy. To begin the treatment process, he starts with Avastin on a monthly basis. As treatment progresses, Dr. Gottlieb said he may "begin to extend the interval between treatments after three or four initial monthly injections." He may extend by two weeks up to 1012 weeks over time. "For eyes that have persistent intraretinal or subretinal fluid despite monthly injections, I will usually try a second medication—either Lucentis or EYLEA," Dr. Gottlieb said. If he extends a treatment interval, he may also try to stop therapy altogether and would have patients return after four to six weeks for OCT and re-examination. "If there is no recurrent exudation, I will again extend the interval between rechecks," Dr. Gottlieb said. He almost always begins treatment with the off-label Avastin rather than on-label treatment options. "It is very much cost driven," he said. According to the AARP, a dose of Avastin is about $30-50, while a dose of Lucentis is about $2,000 per injection. Right macula showing sub-retinal hard exudate in the inferior macula. Small dots of hemorrhage are visible just above the hard exudate. Patient presented with complaints of decreased vision and distortion, right eye. Stephen Russell, M.D., University of Iowa, Iowa City, said he also tends to favor monotherapy for treating AMD. However, he noted that treatment preferences often vary among retina specialists. "I'm not saying that what I'm doing is right for everyone," he said. But Dr. Russell said the way he tends to treat AMD takes into account his patient population, who often come from long distances to be treated. He said he normally uses Avastin. "Depending on how they respond after the initiation period … we will elect to switch to either Lucentis or EYLEA or maintain them on their Avastin," Dr. Russell said. Different treatment and technology choices "I think there is clearly a role for PDT and laser," Dr. Russell said. "The question, however, is how big that role is." He said that PDT with verteporfin treatments are especially helpful for treating polypoidal choroidal vasculopathy (PCV), which may represent a variant or phenotype of age-related macular degeneration. AT A GLANCE • Even among retina specialists, preferences for treatment and therapy for AMD varies. • Among the drugs currently used for AMD, Avastin, Lucentis, and EYLEA work in similar fashions. • Technologies like photodynamic therapy, laser technology, and ICGs are often helpful for treating and monitoring AMD, especially when there is a possibility for polypoidal choroidal vasculopathy or other conditions associated with AMD. However, Dr. Russell does not frequently use these treatments, as the incidence of PCV in the Iowa population is low. Correspondingly, indocyanine green angiography (ICGs) is reserved for patients who are non-responsive to anti-VEGF therapy or where diagnostic confusion may persist. Dr. Kaiser said he believes that laser-based treatment is still a useful continued on page 40 Post-treatment with intraretinal Avastin, there is no evidence of residual intraretinal fluid or the pigment epithelial detachment. Source (all): Justin L. Gottlieb, M.D.